It’s no secret that there are higher rates of workplace violence in healthcare settings than in other workplace environments. In fact, the Bureau of Labor Statistics reports that workers in healthcare are as much as five times more likely to be victims of nonfatal assaults or violent acts than workers in other occupations. In response, The Joint Commission has unveiled a resource center focused on providing guidance and materials for hospitals and other healthcare organizations that are trying to beef up security and better prepare staff to handle disturbances when they occur.

The online guide, dubbed Workplace Violence Prevention Resources, includes policies, procedures, guidelines, toolkits, and other materials that can help organizations better focus their violence prevention efforts. (The resource is available at: http://bit.ly/2d8U2IW.)

It is a topic of high interest these days, and many hospitals are increasing their budgets to help staff feel more secure, but administrators at The Valley Hospital in Ridgewood, NJ, have found that the best approaches are not necessarily the most expensive. In fact, through the implementation of a range of economical interventions, the hospital has been able to drastically reduce the number of workplace violence incidents that take place on the hospital campus. As a result, data show staff feel better about their administrators and their safety.

Daniel Coss, DSc, CPP, CHSP, CHEP, the director of security and public safety at The Valley Hospital, explains that when he first joined the hospital system about three years ago, the risk of workplace violence injuries was high.

“In 2014, we had 55 workplace violence incidents, which was 100% more than we had had two years earlier,” he says. “So we took that on as an initiative to reduce [those incidents].”

Coss notes that he didn’t think one program would be sufficient to solve the problem, but he also didn’t want to overreact and implement a full range of expensive interventions that might not be effective. He decided to develop a holistic approach focused on the following three areas:

  • training and education,
  • the creation of a disturbance response team, and
  • affordable tools that help staff feel safer.

Although the program was designed for the entire hospital, most of the elements were developed with the emergency setting in mind, Coss says.

“The ED is usually one of the top three-to-five high-risk areas that you see on a security risk assessment,” he says. “You really get the most bang for your buck by working in the ED. That is where a lot of the risk is, and that is where a lot of the [violence-related] injuries are ... so it is a natural place to focus.”

The approach implemented at The Valley Hospital certainly has delivered dividends, stopping the escalation of incidents evident in recent years. In 2015, the first year of implementation, there were 26 workplace violence incidents, less than half the number that occurred in 2014. There have been 32 incidents of workplace violence in 2016, so the numbers are up slightly this year, but still far below 2014.

One of the first priorities for Coss was to develop a de-escalation unit, essentially a group of specially trained employees from throughout the hospital who will respond when any hospital clinician or employee calls a “code atlas,” a call for assistance that signifies that a patient is acting out or becoming violent.

“The team was created on the premise that even though nurses are trained to do restraints, it doesn’t mean that they all like to do them, that they are physically capable of doing them ... or that they are good at doing them,” Coss says. “So what we have done is create a code atlas team.”

Each team member is trained for eight hours in de-escalation techniques as well as in how to apply restraints properly to noncompliant patients.

“The team members come from all fields — radiology, nursing, security, and transport. We have them from every interdisciplinary department we have here at the hospital,” Coss explains. “We also make sure that we always have at least three or four members [of the code atlas team] on duty at all times.”

If an emergency nurse sees a patient getting out of control, hyped up, or excited, he or she can use the telecom to report their location and call a code atlas. The members of the team who are on duty will deploy to that nurse’s location.

“They will de-escalate the situation or they will carry out a doctor’s order for restraints; then once the team members have brought the person or situation under control, they will then turn the patient back over to the nurse to continue with that patient’s plan of care,” Coss notes. He adds that all these actions occur under the leadership of the charge nurse on duty.

Interestingly, although it might seem that the implementation of such a team would drive up the use of restraints, the opposite has occurred. The use of the code has increased gradually, along with the team member responses, but the use of physical restraints actually has decreased, according to Coss.

“We have deployed 36 times since we started [the code atlas team in 2015] and we have only used restraints eight times, so it seems as though the de-escalation training, and having a team that is knowledgeable in what they are doing, has had a positive impact,” he says. “If a patient is about to be disruptive for a non-medical reason, they usually change their tune and back off, and we are generally able to de-escalate without using restraints.”

The code atlas team now includes more than 90 hospital employees, all of whom volunteered to take part. However, team members must pass the training requirements and possess the skills necessary to de-escalate potentially dangerous disturbances or outbursts.

“We are picky about who we allow on the team,” Coss notes. “We take volunteers who are comfortable being in these [confrontational] circumstances. They are very good at communicating, and they are very good at dealing with high-stress situations. We get the best of the best for the team, and we don’t select people who don’t want to be there.”

Although there are some large companies that offer de-escalation training, Coss worked with colleagues to develop a training pathway, and then contracted with the local mental health hospital to provide training to staff.

“The mental health facility already provides this type of training to their own employees because it is mandatory in a mental health facility, so we were able to purchase these services from them,” he explains, adding that the cost of the training sessions is roughly $2,500 for about 25 people.

It’s an option that other community hospitals might want to consider as well, Coss continues. Further, he notes that larger hospitals operating psychiatric infrastructures could conceivably provide training in these de-escalation techniques to staff by themselves.

“De-escalation training is psychology 101,” he says.

To ease concerns about violence in the ED, the hospital also offered emergency staff an alert button they can activate whenever they feel threatened or unsafe.

“It is a small tag that hangs from the employee’s badge,” explains Rebecca Young, MAS, BSN, RN, CEN, CPEN, the ED north supervisor at The Valley Hospital. “They can press and hold the button for three seconds, and it will send a silent alarm to security and the charge nurse’s station, and the dashboard will pop up with the employee’s name and their picture and location within the department.” Further, if someone moves once they have pressed the button, the tag will track their location, Young adds.

The tags are an option for emergency staff; they are not required. However, out of 170 staff members, 100 have opted to wear the tags, Young says.

“Some employees are resistant to the tags. They think we are tracking them or they think they [are fully capable] of de-escalating a situation,” she says. “Also, some may be working a day shift and feel like there are enough employees around that they don’t need the tag.”

However, for those who opt to wear them, the tags offer an extra layer of security.

“We have not actually had anyone who has had to hit the button in any kind of unsafe or threatening situation as of yet, but they have the tags there in case they need to,” she adds. “Our idea is that we are giving this solution to them before they are in one of those situations.”

There is good evidence that the tags give nurses some peace of mind.

“We did a workplace safety survey for nurses in September 2015 prior to the implementation of the tags, and we did it again in March 2016, June 2016, and then again in September 2016,” Young explains. The survey contained 10 different questions, some of which queried emergency nurses about their personal experiences. The survey offered a number of answer choices, ranging from strongly disagree to strongly agree. “We specifically looked at ‘I feel safe at work.’ Those [results] shifted to strongly agree and agree versus strongly disagree and disagree.”

Prior to the implementation of the tags in September 2015, 55.56% of the nurses surveyed indicated that they agreed or strongly agreed with the statement “I feel safe at work,” and 44.45% indicated that they disagreed or strongly disagreed. In the follow-up survey one year later, the percentages shifted to 89.47% indicating that they agreed or strongly agreed vs. 10.53% indicating they disagreed or strongly disagreed.

Coss was confident the tags would have a positive effect because he has used them in hospital settings where he worked prior to joining The Valley Hospital.

“Employees like them, and they’re fairly reasonable, costing roughly $50 per tag,” he explains. “They run off of your infrastructure that you already have for Wi-Fi, so this is a low-cost, high-yield program.”

Further, the tag intervention is a much more economical solution than installing hard-wired panic buttons throughout the ED, a tactic The Valley Hospital employed before Coss joined the system.

“On every wall there is a panic button. They are very expensive to put in,” he explains. “But they put them in, and they were rarely used. Most nurses didn’t even know they had them, they didn’t know what their location was, and they didn’t know if they worked.”

Also, Coss notes that the nurses were reluctant to ever use the panic buttons because they didn’t want to activate them in front of patients, fearing that the patients might not react well to their obvious call for help.

“The hospital spent a tremendous amount of money on a program that nobody wanted,” he says.

Conversely, Coss notes that the tag program has been well-received by staff.

“They know the tags are available to them, they have them right there with them; they have their own personal panic alarms,” he says. “They are much happier with this system, and it costs probably one-eighth as much as we spent on the hard-wired panic alarms that staff don’t even use.”

In addition to the tags and the specialized training for code atlas volunteers, all new employees undergo workplace violence training and education. Further, Coss notes that the hospital performs an active shooter drill with multi-agency partners once a year.

“We also do department-level, 30-minute pop-up active shooter drills,” he adds.

Soon, the hospital will have an aggressive gunshot detection system in the lobby as well as the ED.

“Any gunshots that go off or any loud disturbance will set off a silent alarm in security to let us know that something is going on in that location, and then our cameras will automatically [be directed] toward that location where the sound was detected,” Coss explains.

Administrators want to be proactive rather than reactive, Young says.

“Some places might implement these things after having an active shooter. We have never had one, but we are still training as if we will. We are training the staff to know what to do,” she says. “We don’t want there to be an incident, and then learn how to react to it.”

Having made progress on workplace violence prevention, Coss advises colleagues who would like to make similar gains to quit focusing on the latest gadgets.

“It seems as though when people want protection in the ED, they tend to want to invest a lot of money in different devices that cost capital and then are turned down by leadership,” he says.

Instead, start by thinking small and considering what frontline staff in the ED would appreciate, Coss advises.

“The nurses are the experts. They know what they want. Work with them to find an affordable solution for what you are trying to do,” he suggests. “I can put a security guard in the ED for $17 an hour as opposed to spending $170,000 on cameras, and the staff would prefer to have the officer there than having cameras above their heads all day.”

Further, Coss stresses that security isn’t the only factor to consider.

“If you have a hospital, it has got to be open. Metal detectors, armed security, and sally ports [secure, controlled entryways] — those things are only going to turn people away,” he says. “In the era of the Affordable Care Act, you are going to lose patient satisfaction and lose reimbursement, and that is going to hurt you.”

Young reiterates that it is important to consult with staff to find out what they are concerned about.

“You need to know where they want the extra support,” she says. “It is important to do this kind of thing early, so don’t wait until an event occurs.”